peli-nh revised 3/18/2016 preferences for everyday … revised 3/18/2016 2 note to interviewer: when...

PELI-NH Revised 3/18/2016

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Preferences for Everyday Living Inventory (PELI) Nursing Home Version (PELI-NH-Full)

Resident: ______________________ Room Number: _____ Interviewer: ______________ Date: _________

Instructions to the Interviewer

1. Introduce yourself to the resident: “Hello Mr./Mrs./Ms./Dr. _______________. “My name is ________ (name), and I am the _______ (position) here at ________ (community). How are you today?”

2. Describe what you are going to ask the person to do: “This conversation is to help us get to know you better. The reason I’m asking you these questions is that the staff here would like to know what’s important to you. This helps us plan your care around your preferences. If you are uncomfortable with any question, please let me know. Feel free to not answer that question. Do you have any questions?”

3. Explain how the interview works: “I am going to ask you questions about your preferences. I would like to know what your preferences are right now. Some of the questions may ask about things you feel you can no longer do by yourself, but I’d like to know if these activities would be important to you if you could do them with assistance or find a way to do it."

NOTE TO INTERVIEWER: Take out the response card that reads: “Very Important, Somewhat Important, Not Very Important, Not Important at All or Important, But Can’t Do, No Choice” and place it in front of the resident.

4. Explain the response choices: “I am going to ask you whether an activity is important to you or not. I would like you to answer this question either Very Important, Somewhat Important, Not Very Important, Not Important at All or Important, But Can’t Do, No Choice.” For example, if the question is “How important is it to you to watch TV?” you decide what answer best fits how important watching TV is to you. [Show response options to resident]: You could answer “Very Important, Somewhat Important, Not Very Important, Not Important at All or Important, But Can’t Do, No Choice. Do you have any questions?”

NOTE TO INTERVIEWER: Any time the respondent states that an activity is “Not Very Important” or “Not Important at All,” simply check off that box and go to next item.

NOTE TO INTERVIEWER: If a resident responds that they can’t do an activity, first ask, “Why can’t you do it?” Write resident’s response verbatim in the “notes” section. Select “Important, But Can’t Do, No Choice” when the resident indicates that the topic is important, but that he or she is physically unable to participate, or has no choice about participation while staying in the nursing home.

5. When to use alternative response items: If resident does not respond or says “I don’t know,” or if the question is not applicable, check off “No Response/NA.”

6. Explain the nested questions: “Once you have answered how important a preference is to you, I will ask you for details about your preference.”


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NOTE TO INTERVIEWER: When asking questions nested under each preference item, ask the open- ended question first, and write down the resident's response. If the resident cannot answer the question or provide the details about their preference, you can then read them the list of prompts to help them identify the specifics of what they like. If the resident answers with specific information about what they like, then skip the prompts and go to the next nested question or PELI item.

7. When to stop the interview:

a. It is not necessary to do the entire inventory in one session. If the resident becomes fatigued, offer to stop the interview and return at another time. Make an appointment with the resident and leave a card with the time and date of the next interview.

b. If the resident says they would not like to answer any more questions, respect the resident's wishes and discontinue the interview. Mark the interview as incomplete and try to interview a family member, friend or staff person who knows the resident well.

c. If residents give more than five (5) “Non-Responses” in a row, stop the interview and ask the questions of a family member or staff person instead.


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Detailed Preference Interview Resident Name:___________________ Interviewer Name: _______________Date:________ “I am going to ask you questions about your preferences. I would like to know what your preferences are right now. Some of the questions may ask about things you feel you can no longer do by yourself, but I’d like to know if these activities would be important to you if you could do them with assistance or find a way to do it.”

Q01. How important is it to you to choose what name you would like me to use when I greet you?

Importance Check all that Apply

First name:__________________ Nickname:____________________

Mr./Mrs./Ms./Dr.:____________ Other:________________________

Notes:

Q02. How important is it to you to choose when to get up in the morning?


Between 5-6 am 6-7 am 7-8 am

8-9 am After 9 am

Notes:

Q03. How important is it for you to follow a routine when you wake up in the morning?


Relax in bed Watch TV Brush teeth Cigarette

Drink coffee/tea Listen to radio Bathe/wash-up

Comments on order of routine: _______________________________________

Get up right away Less than 15 mins 15-30 mins 31-45 mins

Over 45 mins Depends on:_____ Other:____

Notes:

choice (5)

choice (5)

choice (5)

1a. What name would you like me to use when I greet you?

2a. What time do you usually like to get up in the morning? _______________

3a.What is part of your morning routine?

3b.Would you like to stay in bed before rising? Yes o

3c. If Yes, how long do you like to stay in bed before rising?


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Q04. How important is it to you to choose how often to bathe?


Notes:

Q05. How important is it to you to choose what time of day to bathe?


Morning Evening

Afternoon Night Other: _________________

Notes:

Q06. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? (MDS 3.0, F0400C)


Tub Bath Sponge Bath Shower Bed Bath


-15 mins -20 mins -30mins

How bright do you like the lights:

Which room temperature do you like:

-65 degrees F) -75 degrees F)

>75 degrees F)

choice (5)

4a. How often would you like to bathe?

choice (5)

at all (4)

5a. What time of day do you like to bathe?

choice (5)

6a. What type of bathing do you prefer?

Yes o

6c. Would you like a certain level of lighting when you bathe? No

6d. Would you like a certain room temperature when you bathe? o


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Which do you like to listen to when you bathe:

Notes:

Q07. How important is it to you to choose what clothes to wear? (MDS 3.0, F0400A)


Notes:

Q08. How important is it to you to choose how to care for your mouth?


Brush teeth Brush tongue Floss

Clean/soak dentures

(How often? ________________)

Other: _______________

Notes:

Q09. How important is it to you to choose how often you care for your nails?


Daily Weekly Every other week Monthly

6e. Would you like to listen to something when you bathe? o

Important, but can’t do, no

choice (5)

7a. What do you usually like to wear for the day? _______________________

_____________________________________________ ______________________________________

choice (5)

8a. What do you like to do to care for your mouth?

choice (5)

9a. How often do you like to care for your nails/have your nails cared for?

7b. What do you like to wear to sleep? _____________________________

wear?____________wearto?______________to?sleep?_________________

_____________________

7c. What jewelry do you like to wear? _____________________________


_____________________

7d. Do you like to a carry a:


_____________________

7e. Would you like your clothes arranged in a certain way? Yes No


_____________________

7f. If so, how would you like your clothes arranged? ____________________


_____________________


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Cut/clip cuticles File nails with emery board

Use nail finish/treatments (Type/Brand:______________________)

Polish nails (Type/Brand/Color:____________________________)

Notes:

Q10. How important is it to you to choose how to care for your hair?


Notes:

Shaving Plucking brows/face Hair coloring Hair cut

Comb/brushing Hair styled Shaving legs

Using styling products (Type:______________) (Brand:_______________)

Other: _______________________________________________________

Q11. How important is it to you take a nap when you wish?


Morning Evening/night Afternoon When I want

Notes:

Q12. How important is it to you to set up your own room the way that you want it?


Arranged nightstand/bed table Arrange bed/dresser

Arrange chairs Arrange walker/wheelchair

Arrange closet


Personal keepsakes

Photos

Holiday decorations

Pictures/art

Decor Curtains Other:_____________

9b. What do you like to do to care for your nails/have your nails cared for?

choice (5)

10a. How do you like to care for your hair?

choice (5)

response (9)

11a. When do you usually like to take a nap?

choice (5)

12a. How do you like to set up your room?

12b. Would you like to display/decorate things in your room? No

If yes, what things would you like to decorate your room with?


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Notes:

Clock

Telephone

Tissues

Eye Glasses Lamp/Light Other: _________________________

Q13. How important is it to you to take care of your personal belongings or things? (MDS 3.0, F0400B)


Notes:

Q14. How important is it to keep your room at a certain temperature?


Average (69-72 degrees) On the warm side (>72 degrees)

On the cool side (<69 degrees)

Notes:

Q15. How important is it to you to adjust the lighting in your room?


Dim Moderate Bright

Opened Closed It Depends:_________________________

Notes:

12c. Would you like to keep certain things near your bed? Yes o

12d. Which items do you like to keep by your bed?

choice (5)


choice (5)

choice (5)

13a. What personal belongings do you prefer to take care of yourself?

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

14a. At what temperature do you like to keep your room?

15a. What lighting level do you prefer during the day?

15b. Would you like to be able to adjust the blinds during the day? No

If yes, do you like the keep the shades:


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Q16. How important is it to you to choose your own bedtime? (MDS 3.0, F0400E)


Earlier than 7 pm 7-9 pm 9-10 pm

10-11 pm 11-midnight After midnight

Notes:

Q17. How important is it to follow a routine when you go to bed?


Notes:

Putting on pajamas Pray Have a snack Reading

Listen to radio Watch TV Brush teeth Wash up

Pick out clothes for the next day Other: _______________________

Q18. How important is it to you to set up your bed for comfort?


Notes:

Position/fluff up the pillows Position pillow under limb

# of pillows (____________) # of covers (____________)

Change the room temperature Adjust bed height/settings

Open bedroom door Shut bedroom door

Nightlight on Listen to music (_____________)

Tuck blankets Loosen blankets Close curtains Open windows

choice (5)

16a. What time do you like to go to bed?

choice (5)

17a. Tell me about your bedtime routine:

_______________________________________________________________

_______________________________________________________________

choice (5)

18a. How do you like to set up your bed for comfort?

_______________________________________________________________

_______________________________________________________________

16b. How many hours of sleep do you like at night?

_______________________________________________________________

_______________________________________________________________

17b. What activities do you like to do as part of your bedtime routine?

18b. Which things are important to you in setting up your bed for comfort?


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Q19. How important is it for you to choose your medical care professional?


Physician Nurse Practitioner Physician’s Assistant

Chiropractor Acupuncturist Message Therapist

Hypnotherapist Faith Healer Other:___________________

If yes:

Professional name:____________________________________________________

Professional specialty: _________________________________________________

Professional name: ____________________________________________________

Professional specialty:_________________________________________________

Notes:

Q20. How important is it to you to choose whether your daily caregiver is male or female?


Notes:

Female Male No Preference

Q21. How important is it to you that your daily caregiver knows your needs when going to the bathroom?


Notes:

Notes:

How often I use the bathroom Where I like to use the bathroom

Type of cleansing I like Type of assistance I need

Use of stool softeners, suppositories, laxatives

choice (5)

but can’t do, no

choice (5)

choice (5)

19a. What professionals do you like to see for medical care?

20a. Which gender caregiver do you like for personal care (e.g., showering,

dressing, toileting):

21a. What would you like your daily caregiver to know about your needs when

going to the bathroom?

_______________________________________________________________

_______________________________________________________________

21b. Which bathroom needs would you like your daily caregiver to know

about?

19b. Would you like to continue to see your regular doctor? o


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Q22. How important is it to you to drink alcohol on occasion?


Special occasions Holidays Parties

Dinner Bedtime Other: _______________________

Notes:

Wine Beer Hard liquor Mixed drinks Other:_________

Q23A. Do you use tobacco products?

If no, skip to Q24.

If yes, continue to Q23B.

Q23B. How important is it to you use tobacco products?


Notes:

Cigarettes Cigars Pipe Chewing tobacco

Other:__________________________________________

Q24. How important is it for you to have regular contact with family?


choice (5)

22a. What kind of alcohol do you like to drink on occasion?

choice (5)

but can’t do, no

choice(5)

24a. What family do you enjoy regular contact with?

Name/Relationship: _____________________________________________

How often: _____________________________________________


How often: _____________________________________________


How often: _____________________________________________

22b. On what occasions do you like to drink alcohol?

23c. Where do you like to use tobacco products? _______________________

23d. When do you like to use tobacco products? ________________________

23b. If yes, which tobacco products do you use?


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Visits in person Talking on the phone Email

Sending and getting cards/letters

Being intimate with your spouse or other Other:______________

Notes:

Q25. How important is it to you to have regular contact with friends?


Other residents Friends Other:___________________________

Notes:

Visits in person Talking on the phone Email

Sending and getting cards/letters Other:_____________

24b. With which people would you enjoy regular contact?

24c. Are there family with whom you prefer not to have contact? Yes No

Name/Relationship:_______________________________________________

Name/Relationship:_______________________________________________

24d. Which ways do you like to keep in regular contact with family?

Very important (1)

Somewhat important (2)


choice (5)

25c. Which ways do you like to keep in regular contact with them? 25c. Which ways do you like to keep in regular contact with them?

25a. With what friends do you enjoy regular contact?


How often: _____________________________________________


How often: _____________________________________________

25b. With which friends do you enjoy regular contact? 25b. With which friends do you enjoy regular contact with?


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Q26. How important is it to you to choose who you would like involved in discussions about your care? (modified MDS 3.0, F0400F)


Spouse

Children

Brother

Daily caregiver Social worker Significant other

Grandchildren Sister Nurse

Doctor Friends:________ Other:_______________

_____________

Notes:

Q27. How important is it to you to do what helps you feel better when you are upset?


comedy

Relax Focus on how to solve the problem

Think about happier times Not thinking about what upset you

Other:___________________________________________________

Notes:

choice (5)


choice(5)

Not very important (3)

26a. Once every 3 months there is a meeting of staff to help plan your care.

Would you like to attend the meeting? Yes No

26a. Once every 3 months there is a meeting of staff to help plan your care.

Would you like to attend the meeting? ? Yes No

26c. Which areas of your care do you like to discuss?

26c. Which areas of your care do you like to discuss?

choice (5)


choice(5)


Not important at all (4)

27a. Which things help your feel better when you are upset?

27a. Which things help your feel better when you are upset?

26b. Which people would you like involved in discussions about your care?

26b . Which people would you like involved in discussions about your care?


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Q28. How important is it to you to talk to a mental health professional if you are sad or worried?


Notes:

Q29. How important is it to you to have the staff show that they care about you?


Holding your hand Giving a hug

Saying something nice Joking with you Smiling

nice tone of voice

Notes:

Q30. How important is it for you to have staff show you respect?


you need

Honoring your feelings

Thanking you Listening to you

Other:_____________________

Notes:

choice (5)

Important, but can’t do (5)


Not important at all (4)

28a. Which professionals do you prefer talking to when you are sad or

worried? 28a. Which professionals do you prefer talking to when you are sad or

worried?

choice (5)



29a. Which ways would you like staff to show that they care about you?

29a. Which ways would you like staff to show that they care about you?

choice (5)


choice(5)


30a. In which ways do you like the staff to show you respect? 30a. In which ways do you like the staff to show you respect?

28b. Do you prefer medication rather than talking to someone when you are

upset? Yes No 28b. Do you prefer medication rather than talking to someone when you are

upset? Yes No


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Q31. How important is it for you to be able to use the phone in private? (MDS 3.0, F0400g)


Bedroom

Other:___________________________________________

Notes:

Q32. How important is it to you to have privacy?


Getting dressed/ changing clothes

Notes:

Q33. How important is it to you to lock things up to keep them safe? (modified MDS 3.0, F0400H)


Electronics

Other:____________________________________ __

A safe

Other:_________________________________

Notes:

choice (5)



31a. Where do you like to use the phone in private?

31a. Where do you like to use the phone in private?

choice (5)


choice(5)


32a. Which of these activities do you like to keep private?

32a. Which of these activities do you like to keep private?

choice (5)


choice(5)


33a. What things do you like to keep locked up?

33a. What things do you like to keep locked up?

33b. Which places do you like to lock things to keep them safe?

33b. Which places do you like to lock things to keep them safe?

32b. Which information do you like to keep private?

32b. Which information do you like to keep private?


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Q34. How important is it to you to be involved in choosing your roommate?


Age Hearing ability

How long they have lived here Hygiene (body odors, gas, etc.)

Keeps area clean Not a smoker

Does not wear perfume Quiet/keeps noise level low

Keeps lighting level low Level of disability

TV habits: Personality/character traits:

Quiet Social Active

Polite Not racially prejudiced

Notes:

Q35. How important is it to you to choose what you eat?


Notes:

Q36. How important is it for you to choose when you eat?


Notes:

choice (5)


choice(5)


choice (5)


choice(5)


no

choice (5)


choice(5)


(9)

34a. Which of the following is important to you when choosing a roommate? 34a. Which of the following is important to you when choosing a roommate?

35a. What are your favorite foods for:

Breakfast:______________________________________________________

Lunch:_________________________________________________________

Supper:________________________________________________________

Favorite drinks:_________________________________________________

Condiments:____________________________________________________

Foods I dislike:__________________________________________________

35a. What are your favorite foods for:

Breakfast:______________________________________________________

Lunch:_________________________________________________________

Supper:________________________________________________________

Favorite drinks:_________________________________________________

Condiments:____________________________________________________

Foods I dislike:__________________________________________________

36a. When do you prefer to eat:

Breakfast:______________________________________________________

Lunch:_________________________________________________________

Dinner:________________________________________________________

Whenever I am hungry 36a. When do you prefer to eat:

Breakfast:______________________________________________________

Lunch:_________________________________________________________

Dinner:________________________________________________________

Whenever I am hungry

35b. Do you have certain ethnic or cultural food preferences? Yes No 35b. Do you have certain ethnic or cultural food preferences? Yes No

36b. How much time do you usually like to spend eating a meal?

_______________________________________________________________

______________________________________________________________ 36b. How much time do you usually like to spend eating a meal?

_______________________________________________________________

______________________________________________________________


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Q37. How important is it to you to choose where to eat?


In your room In the dining room

In the cafeteria

At restaurants (How often:___________________________)

______________________________________

Notes:

Q38. How important is it to you to have snacks available between meals?


Notes:

Q39. How important is it for you to eat at restaurants?


(Write name of favorite restaurant:_______________________________)

Notes:

choice (5)


(9)


choice (5)


important at all (4)


choice (5)



37a. Where do you like to eat while you are here/in a nursing home? 37a. Where do you like to eat while you are here/in a nursing home?

38a. Which of the following foods do you like to snack on?

38a. Which of the following foods do you like to snack on?

38b. When do you like to snack?

38b. When do you like to snack?

Morning Afternoon Evening/night Whenever I want

39a. Which kind of restaurants do you like?

39a. Which kind of restaurants do you like?


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Q40. How important is it to you to order take-out food?


Pizza Chinese

Wings Hamburgers

Fish fry BBQ chicken

Italian Japanese

_____

Notes:

Q41. How important is it to you to spend time by yourself?


___

Notes:

Q42. How important is it to you to spend one-on-one time with someone?


Notes:

choice (5)


all (4)


40a. Which kind of take-out food do you like to order? 40a. Which kind of take-out food do you like to order?

choice (5)



41a. In which ways do you like to spend time by yourself?

41a. In which ways do you like to spend time by yourself?

41b. In which places do you like to spend time by yourself?

41b. In which places do you like to spend time by yourself?

Bedroom Outside Other:_____________

choice (5)


choice(5)



42a. Which people do you like to spend one-on-one time with?

42a. Which people do you like to spend one-on-one time with?

42b. What do you like to do with someone one-on-one?

42b. What do you like to do with someone one-on-one?


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Q43. How important is it to do things with groups of people? (MDS 3.0, F0500E)


Friends Other residents

Roommate Family members

Notes:

Q44. How important is it to you to meet new people?


Notes:

Q45. How important is it to you to be a member of a club?


Book club Glee club

Card club Computer club

choice (5)




43a. What do you like to do with groups of people? _____________________

_______________________________________________________________ 43a. What do you like to do with groups of people? _____________________

_______________________________________________________________

choice (5)


choice(5)


44a. In which ways do you like to meet new people?

44a. In which ways do you like to meet new people?

45a. Which kind of club(s) did you enjoy in the past?

45a. Which kind of club(s) did you enjoy in the past?

43b. Which type of person do you enjoy in a group? 43b. Which type of person do you enjoy in a group?

43c. How many people do you like when doing things in a group? 43c. How many people do you like when doing things in a group?

no

choice (5)



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Book club Glee club

Card club Computer club

Notes:

Q46. How important is it to be around children?


Grandchildren Great Grandchildren School groups

Other residents’ visitors

Notes:

Watching them play Playing with them

Talking with them Teaching them

Q47. How important is it to you to volunteer your time?


Reading with/teaching children

Coaching a sports team Shopping for other people

Helping people learn the computer

unteer activities

Reading with/teaching children

Coaching a sports team Shopping for other residents

Helping people learn the computer

raising

Notes:

45b. What kind of clubs do you enjoy now?

45b. What kind of clubs do you enjoy now?

choice (5)


choice(5)

all (4)

)


46a. What children do you enjoy doing activities with? 46a. What children do you enjoy doing activities with?

46b. What activities involving children do you enjoy? 46b. What activities involving children do you enjoy?

choice (5)


all (4)


47a. Have you volunteered your time in the past? Yes No

47a. Have you volunteered your time in the past? Yes No

47b. If yes, which ways have you volunteered your time in the past?

47b. If yes, which ways have you volunteered your time in the past?

47c. How do you like to volunteer your time now?

47c. How do you like to volunteer your time now?



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Q48. How important is it to participate in religious services or practices? (MDS 3.0, Section F, F0500H)


Read/study the Torah/Bible/Koran/other Attend religious services

Pray/meditate

Watch service on TV

ones? ____________________________________)

Notes:

Q49. How important is it to you to participate in your cultural traditions?


Eating traditional food Celebrations Holidays

Religious traditions

Notes:


choice (5)


choice(5)


(4)

48a. What is your religious background?______________________________

_______________________________________________________________

48a. What is your religious background?______________________________

_______________________________________________________________

48c. If yes, which organization do you belong to? 48c. If yes, which organization do you belong to?

choice (5)



49a. In which cultural traditions do you like to participate? 49a. In which cultural traditions do you like to participate?

48b. Do you belong to a religious organization? Yes No


48d. If so, what is the name? _______________________________________ 48d. If so, what is the name? _______________________________________ 48e. Which religious services or practices do you like? 48e. Which religious services or practices do you like?


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Q50. How important is it to you to reminisce about the past?


Family Pets Friends TV shows

Hobbies

Notes:

Q51. How important is it to you to give gifts?


Notes:

choice (5)


choice(5)

Non response (9)


choice (5)


choice(5)



50a. Which topics do you like to reminisce about?

? 49a. In which cultural traditions do you like to participate?

50b. With which people would you like to reminisce?

? 49a. In which cultural traditions do you like to participate?

50c. Do you like to reminisce with a group of people? Yes No


51a. To which people would you like to give gifts?


51b. Which kind of gifts do you like to give?


51c. Is it important to you to give gifts on holidays or special occasions?

Yes No


If yes, on which holidays or special occasions would you enjoy giving gifts?



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Q52. How important is it to you to go shopping?


store

___________________________________________________________

Write names of favorite stores if given: ____________________________________

____________________________________________________________________

Notes:

Q53. How important is it to you to do things away from here?


to the theater

______________________

Notes:

Q54. How important is it to you to attend entertainment events?


Notes:

choice (5)




choice (5)


choice(5)


52a. At which stores do you like to shop?


53a. Which kinds of things would you like to do away from here?


53b. How long do you like to spend away from here?


53c. Whom do you like to be with if you were away from here?


choice (5)


(4)


54a. Which entertainment events did you enjoy in the past?



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Q55. How important is it to you to go outside to get fresh air when the weather is good? (MDS 3.0, Section F, F0500G)


-3 times a week -5 times a week

Notes:

Q56. How important is it to you to take care of the place you live?


laundry

Notes:

Q57. How important is it to you to do outdoor tasks?


Notes:

choice(5)


choice(5)


choice (5)


Non response (9)



choice (5)


choice(5)


55a. In which type of weather do you like to go outside?


55b. Which things do you like to do outside when the weather is good?


55c. How many times do you like to go outside in a week?


56a. Which tasks do you like to do to care for the place you live?


57a. Which tasks do you like to do to care for the place you live?



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Q58. How important is it to you to be around animals such as pets? (MDS 3.0, Section F, F0500C)


If yes, what kind? ____________________________________________________

Notes:

Q59. How important is it to you to keep up with the news?(modified MDS 3.0, F0500D)


with another person _________

Notes:

Q60. How important is it to you to learn about topics that interest you?


______________ Eye problems Hearing problems

professional

Notes:

choice (5)



can’t do, no

choice (5)


choice(5)


response (9)

do, no

choice (5)


choice(5)


(9)

58a. Which kind of animals do you like to be around?


58b. Which type of contact do you enjoy with animals?


58c. Are you allergic to animals? Yes No


59a. Which ways do you like to keep up with the news?


60a. Which topics would you like to learn more about?


60b. Which ways would you like to learn about topics that interest you?



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Q61A. Do you have difficulties reading due to eyesight?

If no, skip to Q61C.

If yes, continue to Q61B.

Q61B. (If yes) I'd like to know if these activities would be important to you if you could do them with assistance or find a way to do it. How important is it to you to have reading options for low vision available to you? (modified MDS 3.0, F0500A)


Notes:

Go to question Q62.

Q61C. (If no) How important is it to you to have reading materials available to you? (modified MDS 3.0, F0500A)


Notes:

choice (5)



choice (5)


choice(5)


61d. Which reading options would you like available?


61e. Which materials do you like to read?


61f. Would you like to be a member of a book club? Yes No


61g. Would you like to read on an electronic tablet, e-reader, or notebook?

Yes No


61e. Which materials do you like to read?


61f. Would you like to be a member of a book club? Yes No


61g. Would you like to read on an electronic tablet, e-reader, or notebook?

Yes No



26

Q62. How important is it to you to exercise?


-ups

Notes:

Q63. How important are sports to you?


Notes:

choice (5)


choice(5)


response (9)

choice (5)


choice(5)



62a. Which types of exercise do you like?


63a. Which types of sports have you enjoyed in the past?


63b. Which types of sports would you like now?


63c. Which ways do you like to participate in sports?



27

Q64. How important is it to you to play games?


games

Video games (e.g. Wii)

Notes:

Q65. How important is it to you to take care of plants?


about plants

Notes:

choice (5)


choice(5)



choice (5)


choice(5)


64a. Which types of games do you like to play?


64b. With which people do you like to play games?


65a. In which ways do you like to care for plants?



28

Q66. How important is it to you to be involved in cooking?


Attending cooking class

Notes:

Q67. How important is it to you to watch or listen to TV?


Write names of favorite programs, if given:_________________________________

____________________________________________________________________

____________________________________________________________________

Notes:

Q68. How important is it to you to watch movies with other people?


room

other ___________ Other:_____________

Notes:

choice (5)


choice(5)


66a. Which ways do you like to be involved in cooking?


choice(5)



choice (5)


choice(5)


67a. Which type of TV programs do you like to watch?


68a. Which type of movies do you like to watch with other people?


68b. Which places do you like to watch movies with other people?


68c. Which people do you like to watch movies with?



29

Q69. How important is it to you to listen to music you like? (MDS 3.0, Section F, F0500B)


Other:______________________________

If yes:______________________________________________________________

If yes:______________________________________________________________

Notes:

Q70. How important is it to you to use the computer?


If yes, what would you like to learn?______________________________________

Notes:

can’t do, no

choice (5)



choice (5)


choice(5)



69a. Which kinds of music do you like?


69b. Do you have a favorite era of music? Yes No


69c. Do you have favorite musicians/musical groups? Yes No


69d. Which ways do you like to listen to music?


70a. Which activities would you like to do on the computer?


70b. Would you like to learn about using the computer? Yes No



30

Q71. How important is it to you to do your favorite hobbies?


____________________ __

Notes:

Q72. How important is it to you to do your favorite activities? (MDS 3.0, F0500F)


Notes:

choice (5)


choice(5)



choice (5)


choice(5)

Non response (9)


71a. Which kinds of hobbies do you like?


72a. What are you favorite activities? ________________________________

_______________________________________________________________

_______________________________________________________________


72b. With whom would you like to do your favorite activities?



31

1=Very Important ______________________ 2=Somewhat Important ______________________ 3=Not Very Important ______________________ 4=Not Important at All ______________________ 5=Important, But Can't Do, No Choice

peli-nh revised 3/18/2016 preferences for everyday … revised 3/18/2016 2 note to interviewer: when...

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